Professional Documents
Culture Documents
Hemiblock
Bifascicular Block
Take-Home Points
Distention
Hypertrophy
Pericarditis
Electrolyte Imbalance
Hypokalemia
Hypercalcemia
8
Hypocalcemia
Pulmonary Embolism
Early Repolarization
Hypothermia
Brugada Syndrome
Take-Home Points
Take-Home Points
9
Extensive Anterior Myocardial Infarction
Take-Home Points
Goals of Management
Take-Home Points
10
Glossary
Index
11
Copyright
Notices
12
As new research and experience broaden our understanding,
changes in research methods, professional practices, or medical
treatment may become necessary.
To the fullest extent of the law, neither the publisher nor the
authors, contributors, or editors, assume any liability for any
injury and/or damage to persons or property as a matter of
products liability, negligence or otherwise, or from any use or
operation of any methods, products, instructions, or ideas
contained in the material herein.
13
Wisconsin.
| St. Louis, Missouri : Elsevier, [2017] | Originally published as:
Basic
dysrhythmias : interpretation and management / Robert J. Huszar
(St. Louis
: Mosby, 1988). | Includes index.
Identifiers: LCCN 2016028810 | ISBN 9780323355759 (pbk.)
Subjects: LCSH: Arrhythmia. | Electrocardiography--Interpretation.
Classification: LCC RC685.A65 H89 2017 | DDC 616.1/207547--dc23
LC record available at https://lccn.loc.gov/2016028810
Printed in China
14
Dedication
My wife, Karen.
I love you.
Keith Wesley, MD, FACEP
15
About the Author
Keith Wesley is board certified in emergency medicine and holds
subspecialty certification in emergency medical service (EMS)
medicine. Originally from Tyler, Texas, he graduated from Brigham
Young University in 1982 and Baylor College of Medicine in
Houston, Texas, in 1986. He completed an emergency medicine
residency at Methodist Hospital in Indianapolis, Indiana, where he
gained his first exposure to EMS flying air medical missions.
Dr. Wesley has been involved in EMS since 1989, working with
many services in Wisconsin. In 1992 he was selected by the
governor as a founding member of the Wisconsin State Physician
Advisory Committee and served for 12 years, the last 4 years as
chair.
From 1992 to 2004 Dr. Wesley was a clinical assistant professor at
the University of Wisconsin Family Practice Residency in Eau
Claire, Wisconsin. There he was responsible for the training and
education of family practice residents rotating through the
emergency department.
In 2006 Dr. Wesley was selected as the Wisconsin State EMS
medical director. He held that position until 2008, when he moved
his practice to Minnesota and accepted the position of Minnesota
State EMS medical director, which he held until 2010. He currently
works for HealthEast in St. Paul, where he is the EMS medical
director for Medical Transportation.
Dr. Wesley is a former chair of the National Council of State EMS
Medical Directors and is active in the National Association of EMS
Physicians. He has coauthored four textbooks and numerous
16
articles and papers and is a frequent speaker at state and national
conferences. He is currently on the editorial board of JEMS
magazine.
An active member of the American College of Emergency
Physicians and the National Association of EMS Physicians, Dr.
Wesley has been actively involved in creating educational
programs for medical and nursing students, EMTs, and physicians.
When not engaged in EMS duties, Dr. Wesley enjoys spending
time with his wife, Karen, who is a retired police officer and tactical
paramedic. They live in Eau Claire, Wisconsin, with their golden
retriever, Charly, and shitzu, Sammie.
17
Foreword
This fifth edition of Dr. Wesley’s Huszar’s ECG and 12-Lead
Interpretation marks the 115th year since the technique known as
electrocardiography was first reported by the eminent Dutch
physiologist William Einthoven. With this fundamental discovery
came a new methodology that has forever changed the face of
medicine and guided the care of patients with heart disease,
especially those with acute cardiac pathology. Given that the
correct interpretation of an electrocardiogram provides a
noninvasive legend to diagnosing and treating heart rhythm
disorders and acute coronary syndromes, it is critical that all
clinicians who care for patients with the potential for cardiac
disease feel comfortable knowing how to understand and use this
vital tool.
In the span of a little over a century since the ECG was
introduced, the squiggly lines of print on a piece of paper have
become a clinical guide and call to action. Knowing how to
interpret this code and what to do with the correct interpretation
requires knowledge and practice. This new edition provides this
comprehensive information in a concise and straightforward
manner. Each chapter is user friendly and provides state-of-the art
information. Dr. Wesley is an emergency department physician,
EMS medical director with decades of clinical experience, and a
skilled writer and educator. He has supplemented the previous
edition with up-to-date information, especially in the area of the
treatment of acute coronary syndromes and cardiac arrest. The text
is easy to read, the figures are refreshing and easy to understand,
and each section contains a self-assessment test to help reinforce the
18
key messages.
This book builds on the adage that knowledge is power: this book
provides knowledge that can be life-saving. Rooted upon the
foundation of vector cardiography and electrophysiology that
forms the geometric and physiological underpinnings of ECG
analysis and understanding, the chapters on ECG interpretation,
pacemakers and defibrillators, and treatment algorithms are a
translational toolkit for emergency medical technicians,
paramedics, nursing students and nurses, medical students, and
physicians. They provide a means to learn at one’s own pace and
then deliver care based on a solid understanding of the essentials of
cardiac pathophysiology, especially in the acute care setting. This
book is particularly helpful for the new clinician: it helps take the
fear out of treating patients with life-threatening cardiac
abnormalities and empowers them by providing the tools for
action.
Finally it is important to re-emphasize that although ECG and 12-
Lead Interpretation is encyclopedic in size and content, it is
organized in a way such that it can be used on the job in the
emergency department, on the telemetry wards, in an intensive care
unit, or on the street in the back of an ambulance. When taking care
of a patient with a dysrhythmia or acute infarction, the clinician can
see this text as a blueprint and will not need to look beyond it for
complete guidance.
As you turn the pages of this book as a reference or use it to learn
the essentials of cardiac care, I hope you enjoy this learning process.
We are living in an extraordinary age in medicine, and the teaching
messages in this text reflect the incredible progress over the past
century. From the first ECG tracings reported at the beginning of
the twentieth century, we now have the clinical tools to transform
the information from an ECG into definitive and life-saving care.
That translational process is dynamic: this text provides the key up-
to-date pathways to successfully treat patients and save lives based
on the widespread use of the cardiac electrogram. I encourage you
to use it as a vital resource.
Keith Lurie, MD, Cardiac Electrophysiologist, Professor of Emergency and
Internal Medicine, University of Minnesota
19
Publisher’s Note
The author and publisher have made every attempt to check
dosages and advanced life support content for accuracy. The care
procedures presented here represent accepted practices in the
United States. They are not offered as a standard of care. Advanced
life support–level emergency care is performed under the authority
of a licensed physician. It is the student’s responsibility to know
and follow local care protocols as provided by his or her medical
advisors. It is also the student’s responsibility to stay informed of
emergency care procedure changes, including the most recent
guidelines set forth by the American Heart Association and printed
in their textbooks.
20
Preface
This text was written to teach medical, nursing, and EMS providers
basic skills in cardiac rhythm interpretation. It also provides a
wealth of advanced instruction in the clinical signs, symptoms, and
management of patients presenting with cardiac dysrhythmias.
With the advent of ECG monitoring has come readily accessible
12-lead electrocardiography, an essential tool in the detection and
management of acute coronary syndromes. Accordingly, this
edition has several chapters dedicated to 12-lead ECG
interpretation. The book also offers in-depth coverage of the
pathophysiology, clinical signs and symptoms, and management of
acute coronary syndromes.
Each rhythm is first presented in its classic form, with a quick-
reference box outlining its unique characteristics. The
accompanying text contains a detailed explanation of these features,
as well as a discussion of the range of normal variability and the
possible exceptions to each pattern. Many of the rhythm strips are
from real patients. Thus they do not necessarily have all of the
classic characteristics described in the text. That’s the challenge of
ECG rhythm interpretation.
The treatment algorithms are based on the latest resuscitation
guidelines issued by the American Heart Association and the
American College of Cardiology. However, because the science
continues to evolve and local policy and protocol may vary, it’s
important to stay abreast of new treatments as they evolve.
This edition of the text offers information in a more visual format
that allows quick reference and review.
21
ECG Keys Boxes
Skillful diagnosis and treatment of rhythm disorders are based on
mastery of a body of foundational knowledge. ECG Keys boxes
highlight this core information, such as clinical indications and end
points for administration of certain agents.
Author’s Notes
It’s critical to be aware of the broad range of variables that might
make a patient’s rhythm look less than classic. In Author’s Notes,
Dr. Wesley points out some of these considerations. Many of the
notes pertain to diagnosis or treatment and not strictly
interpretation. For example, Dr. Wesley advises asking patients
about discomfort, not just pain, when taking a history. Author’s
Notes also point out ways in which Dr. Wesley’s recommendations
may differ from the course of action suggested in other texts or
required by local protocol.
Key Definitions
This text contains a full glossary. Key Definitions call attention to
the most relevant terms, making them easily accessible while you’re
reviewing the surrounding topics. These on-page definitions often
elaborate on the information given in the glossary.
Take-Home Points
When you don’t have time to read or re-read an entire chapter,
Take-Home Points hit the highlights. This bulleted summary gives
you need-to-know information about the most important topics
covered.
22
assessment questions in Appendix C, they also give you additional
practice to increase your competency in ECG interpretation. If
you’re particularly interested in ECG axis interpretation, Appendix
A provides an extensive review of the subject.
Each chapter in this book builds on the skills and principles
explored earlier. By moving sequentially through the chapters,
you’ll have all the tools you need for accurate rhythm
interpretation, diagnosis, and clinical management. If you’re a
seasoned veteran, you already know how rewarding such
competence can be. If you’re a student, welcome to this exciting,
critical, and often challenging subject.
Keith Wesley, MD, FACEP
23
Acknowledgments
First, I would like to thank the dedicated men and women of
HealthEast Medical Transportation and United Emergency Medical
Response, who provided me encouragement, criticism, and reams
of rhythm strips and 12 leads.
Next, I must acknowledge the successful foundation upon which
this book is based. Dr. Huszar expertly crafted this text in its first
three editions. To be given the opportunity to carry on where this
great man left off is an honor.
I wish to thank Drs. Josh Kary, Erick Weisnicht, and Adam
Oehrlein, along with their staff at Healthsource in St. Paul. They
kept my spine aligned during the long months of writing this text
while I was recovering from prostate cancer. I could not have done
it without your healing hands.
And to my lovely daughter-in-law, Brenna Marie Wesley, who
redrew many pieces of art in this text. You are as talented as you
are beautiful. Please visit BrennaWesley.wix.com to see her work.
Finally, no author can succeed without an excellent editor.
Melissa Kinsey accepted the challenge of working with an old,
cantankerous physician and made this book a reality. She took my
passive clinical diatribes and turned them into concise and
understandable prose. Thank you, Mel.
Keith Wesley, MD, FACEP
Publisher’s Acknowledgments
24
The editors wish to acknowledge the reviewers of the fifth edition
of this book for their invaluable assistance in developing and fine-
tuning this manuscript.
Vincent M. DiGiulio Jr. BS, EMT-CC, EMT–Critical Care, Binghamton,
New York
Prof.
Hugh Grantham, ASM, MBBS, FRACGP, Professor of Paramedics,
Flinders University, South Australia
Brent M. Lopez, MSN, RN, LPN Instructor, Applied Tech, St. Louis, Missouri
25
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